Form A - UCI International Center

UCI International Center 

H1‐B Checklist for Prospective Employees 

SECTION A. About the Employee and Position at UCI 

Name: 

Family: First: Middle: 

Gender: Male: Female: 

Do you have any 

dependents 

Yes: (please complete Section B) 

No: 

Date of Birth: Month: Day: Year: 

Birthplace: 

City: Province: Country: 

Country of Citizenship: 

Alien Registration # (if any): 

Passport #: 

Date Passport issued: Month: Day: Year: 

Passport expiration date: Month: Day: Year: 

Student & Exchange Visitor Information System 

(SEVIS) # (if any, (please list all): 

Have you ever had an EAD (Employment 

Authorization Document) card: 

Employment Authorization Document (EAD) # 

(if any, please list all): 

Street: 

Address Outside the 

United States: 

No: 

Yes: (if yes, please complete below) 

State/Province: 

City: Postal Code: Country: 

You are: 

In the US or will apply for a COS/COE in the US: 

Not in the US and/or will apply for an H-1B visa outside the US: 

If you are in the United States 

or will apply for a COS/COE in 

the US, please provide 

current address: 

Street: 

State: 

City: 

Zip Code: 

Highest Degree obtained: Bachelor’s: Masters: Doctoral: Major: 

Please provide copy of the degree certificate(s), with translation if applicable (if degree certificate doesn’t list the 

major, please include transcripts as well) 

UCI International Center • Irvine, CA 92697‐5255 • P: 949.824.7249 • F: 949.824.3090 • intl@uci.edu • www.ic.uci.edu 

IC Office Use Only: Date Received: Advisor’s Initials: Ready for Pick‐Up On: | Revised On 7.25.2014



If you are in the United 

States, 

or will apply for a COS/COE 

in the US, please provide the 

following: 

Type of current Visa status: 

Begin date of current status: 

Month: Day: Year: 

Expiration date of current status: 


Was the most 

recent entry to the 

US from Canada or 

Mexico: 

No Yes: 

I-94 expiration date: 

I-94 

expiration 

date: 

D/S or 

Date of most recent entry to the US: Month: Day: Year: 


Contact Information: 

Phone # (work/home): Phone # (Cell): Email: 

United States Consulate where H-1B visa will 

be obtained if outside the US or COS/COE 

can’t be granted in United States (if a 

Canadian citizen, please list inspection 

facility): 

Consulate: 

Pre-flight Inspection: 

Port of Entry 

City (Outside the US): 

Country: 

Have you ever held H 

or L status: 

No: 


Status Type: 

Period of Stay (month/day/year) 

From: 

To: 

If more than one, please add below: 





Have you ever 

held J-1 or J-2 status: 

No: Yes: 

(If yes, please complete below and provide all supporting documents DS- 

2019, Visa, I-612 waiver, etc.) 

Period of Stay (month/day/year): 

From: To: From: To: 

Were you ever subject to 

212[e], the Two-Year 

No: 


Home Residency 

Requirement: 

If Yes, did you receive 

the waiver: 

No: 

Yes: 

CERTAIN, BUT NOT ALL, J-1 EXCHANGE VISITORS MAY BE SUBJECT TO A TWO-YEAR HOME COUNTRY 

PHYSICAL PRESENCE REQUIREMENTAND ARE NOT ELIGIBLE FOR H-1B STATUS UNTIL THE 

REQUIREMENT HAS BEEN SATISFIED OR WAIVED BY THE USCIS BASED ON A RECOMMENDATION FROM 

THE U.S. DEPARTMENT OF STATE. IF THIS TWO-YEAR REQUIREMENT DOES NOT APPLY, YOU ARE 

ELIGIBLE FOR H-1B STATUS. IF YOU HAVE PREVIOUSLY BEEN A J-1/J-2 EXCHANGE VISITOR, AND ARE 

UNCERTAIN AS TO WHETHER THIS REQUIREMENT APPLIES TO YOU, PLEASE CONSULT WITH UCI’S 

INTERNATIONAL CENTER. 

Have you ever held F-1 

or F-2 status 

No: 

Yes: (if yes, please provide all supporting documents I-20, EAD, Visa, etc.) 

Do you have a 

Permanent Resident 

Application in Process: 

No: 

Yes: (if yes, please provide details below) 

Are you planning to 

travel outside of the 

United States within 

the next six (6) 

months: 

No: 


Has any H-1B petition 

filed for the alien ever 

been denied 

No: 






Are you in the removal 

proceedings 

No: 


Has any visa stamp 

application or any 

other filing with USCIS 

filed by the alien ever 

been denied 

No: 


Single job location (specify City/County/State): _______________________ 

________________________________________________________________ 

Job is peripatetic in nature; Normal duties include frequent travel from 

location to location 

Job will include occasional travel of 10 consecutive days or less 

Location of 

Employment: 

Job will include SHORT-TERM PLACEMENTS in other work location(s) of: 

Less than 30 days during one year period 

Up to 60 days during one year period 

More than 60 days in one year period; Employee will maintain 

“office” at the primary location 

Specify other work location(s) (specify City/County/State):________________ 

Job includes other work location for more than 60 days per year which the 

employee will not maintain an “office” at the primary work location, specify 

other work location(s) (specify City/County/State):______________________ 





Hiring Department: 

Payroll title: 

Payroll title code: 

About the position 

(please check with 

your department) 

Salary per year on H-1B start date: $ 

/year 

Yes: No: 

Does this position 

if yes, # of employees will supervise: 

supervise the work of 

other employees 

Has this appointment 

been approved 

Dates of H-1B employment 

(month/day/year): 

Yes: No: 

(if no, please check with International Center if it’s 

ok to continue with the H-1B request) 

From: 

To: 

SECTION B. About the H-1B Beneficiary’s Dependents (Spouse and Children Under 21) 

Full Name: 

Relationship to you: 


Country of birth: 

Date of birth: 


Full Name: 

Current Visa status: 










Full Name: 







Full Name:

Form A - UCI International Center

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